A 'significant and disturbing trend'

After the Texas City tragedy, the Chemical Safety Board and an independent panel commissioned by BP found the company did not pay enough attention to process safety.

Trade associations point to low recordable injury rates as evidence of improved safety in the refining industry.

In 2007, OSHA stepped up inspections of refineries for compliance with the process safety management standard and found many problems with identifying and correcting equipment deficiencies.

On March 23 – the fifth anniversary of a series of explosions that killed 15 workers and injured 180 at BP’s Texas City refinery – both the Chemical Safety Board and the Department of Labor urged oil refiners to rededicate their safety efforts. Less than two weeks later, a major fire broke out after routine maintenance at a Tesoro Corp. refinery in Anacortes, WA.
The April 2 blaze killed seven workers, making it the deadliest U.S. refinery incident since the 2005 Texas City disaster. Once again, questions surfaced about safety in the refining industry.

The nation’s 150 refineries represent only a fraction of the industrial facilities under CSB jurisdiction, yet nine of the agency’s 18 ongoing investigations involved refineries at press time. CSB Chairman John Bresland acknowledged the problem in a statement after the Tesoro incident. “This is a significant and disturbing trend that the refining industry needs to address immediately,” he said.
Representatives from government, industry and labor generally agree that refiners made positive changes in the wake of the Texas City disaster. But while trade groups point to low injury rates as proof of safety, federal and union officials are concerned about what appears to be a pattern of problems at petroleum facilities.

In May, assistant OSHA administrator Jordan Barab called for systemic reform and new metrics to measure safety. Speaking at the National Petrochemical and Refiners Association National Safety Conference in San Antonio, he told attendees, “Your workers are dying on the job and it has to stop.”

Although individual incidents have different technical causes, experts focus on two core issues for the industry: process safety management and safety culture. In 2007, CSB and an independent panel commissioned by BP (chaired by former Secretary of State James A. Baker III and known as the Baker panel) issued reports analyzing BP’s failures in both areas. Other companies used the findings to examine their own operations. And yet serious incidents continue to occur.
“They read the Baker report, they embraced the Baker report, but what is the follow-up to that?” asked Najmedin Meshkati, professor of engineering at the University of Southern California in Los Angeles. “Who is accountable to make sure that the Baker report’s findings on safety culture have been incorporated across the country, not only at British Petroleum refineries, [but also] in independent refineries and major oil company refineries?”

Texas City raises awareness

CSB traced the Texas City disaster to a blowdown drum overfilling with highly flammable liquid hydrocarbons, which led to a sudden geyser-like release and the formation of a vapor cloud that ignited.

OSHA responded with a record $21 million fine against BP Products North America, and last year slapped BP with an additional $87 million penalty for allegedly failing to correct hazards identified after the incident. BP currently is contesting those citations. But the company continues to face scrutiny. In March, OSHA proposed $3 million in fines against BP and the BP-Husky Refining LLC refinery in Oregon, OH. In April, an oil rig leased to BP exploded and sank, killing 11 workers and spilling massive amounts of oil into the Gulf of Mexico. And in early May, Washington state’s Department of Labor & Industries cited the BP Cherry Point refinery for 13 serious violations as part of a nationwide refinery audit.

Scott Berger, executive director of the New York-based Center for Chemical Process Safety, which is part of the American Institute of Chemical Engineers, said the 2005 Texas City incident impacted the entire industry. “What BP did, I think, was raise everybody’s awareness that these kinds of incidents can really happen and really focused their attention on the effectiveness of their programs, and of their culture, and measuring performance,” he said.

In 2007, both CSB and the Baker panel concluded that BP emphasized personal safety but gave inadequate attention to process safety. In its final report, CSB said cost-cutting hurt safety programs and critical maintenance at the aging facility, workers likely suffered from fatigue, and the company ignored warning signs. BP also lacked effective safety leadership and had “not instilled a common, unifying process safety culture among its U.S. refineries,” according to the Baker report.
BP did not respond to requests for comment. However, in December 2005 the company announced it would invest $1 billion in improvement and maintenance at the Texas City refinery.

Measuring safety

In 2009, the United Steelworkers issued flyers warning “it’s only a matter of time” before another serious refinery incident occurs.
About two years earlier, the Pittsburgh-based union released survey results showing refinery conditions similar to those at Texas City were “pervasive.” Of the 51 unionized refineries that responded to the survey, 90 percent reported having at least one hazardous condition, such as atmospheric vents on process units, trailers near high-risk facilities, and non-essential personnel in vulnerable areas during startup and shutdown.

Ron Chittim, senior policy advisor for the Washington-based American Petroleum Institute, disputed USW claims of an industrywide safety problem. He cited data from the Bureau of Labor Statistics showing refineries had a recordable injury rate of 1.1 per 100 full-time workers in 2008, compared with 5 for the manufacturing sector as a whole.

“I think it’s unfortunate that USW makes claims that we don’t care about safety and we don’t learn from lessons because nothing could be further from the truth, and the data supports our improved safety record,” he said.
Bill Hoyle, retired manager of investigations for CSB and USW safety consultant, disagreed with the assertion that low personal injury rates indicate a safe work environment. “What we found in the CSB investigation is that BP Texas City had a very low injury rate, measured by the OSHA recordable rate, yet their process safety program and infrastructure, as well as their safety culture, was in shambles,” Hoyle said.

Charles Drevna, president of the National Petrochemical and Refiners Association in Washington, said refineries protect workers better than almost any other industry in manufacturing. “It’s not the industry,” Drevna said. “It’s a community, and communities want to take care of each other.”

However, at the association’s safety conference in May, Barab took refiners to task for boasting about their safety records and presenting awards to members “based solely on a lack of slips, trips and falls.” NPRA gave Tesoro refinery in Anacortes its Gold Award for safety performance in 2006 and 2007.

Federal oversight

In CSB’s report on the Texas City disaster, investigators said that as a result of OSHA’s emphasis on inspecting facilities with a high injury rate, not enough attention was focused on preventing process safety incidents.

OSHA launched a National Emphasis Program for refineries in 2007 to help ensure compliance with the process safety management standard. The regulation lays out 14 elements employers must address to prevent or minimize the effects of hazardous materials releases (see “OSHA’s process safety management standard,” p. 40). Documents show that in the program’s first year, OSHA inspected 14 refineries and issued 348 citations – particularly related to identifying and correcting deficiencies in process equipment.
However, the NEP does not cover all refineries. OSHA has jurisdiction in 29 states; State Plan programs are encouraged but not required to conduct their own inspections. Refineries participating in the Voluntary Protection Programs also are exempt.
OSHA started a similar program for chemical facilities in 2009. But simply checking the elements in the PSM standard is not enough to ensure safety, according to Meshkati, who has been studying the issue for 20 years. “To me, that is bare minimum; that is the foundation,” he said.

In his opinion, the industry needs to address cumulative fatigue, mental and physical operator workload, and information processing behavior. Meshkati also would like CSB to issue a “most wanted” list of refinery safety improvements similar to the one compiled by the National Transportation Safety Board.

Kim Nibarger, health and safety specialist for the United Steelworkers, worked at the Equilon Puget Sound Refinery in Anacortes, WA, when an explosion killed six workers in 1998. Nibarger said refineries experience a number of releases and mistakenly rely on the pressure relief valve to activate. “Our contention is when you’re experiencing events like that, you should be looking further up the system to see what the problem is and correcting that rather than just relying on that last line of defense working,” he said.
While applauding the work of OSHA compliance officers, Nibarger expressed concern about companies using the court system to erase citations. “I see issues that are cited time and again disappear because I don’t think the government has the time or the money to spend in long, drawn-out legal battles,” he said.

As part of the federal NEP, Washington state L&I cited Tesoro’s Anacortes refinery for 17 serious safety and health violations in 2009. Tesoro appealed, and the department dropped 14 violations as part of a settlement agreement. It is unclear whether there is a connection between the violations and the April fire.

From a larger perspective, Bresland said CSB has yet to identify common threads among different refinery incidents. However, Texas-based engineer and safety consultant Mike Sawyer sees a clear similarity. He reviewed BP’s compliance with the OSHA settlement on behalf of victims’ families and has worked for attorneys on other refinery cases.
“The commonalty that I find most disturbing in refinery-related incidents and process-related incidents, for that matter, is that the root causes always seem to stem from a failure to understand the risk of the operation,” Sawyer said. That may be as simple as a worker not knowing the correct pressure or temperature for the process, he added.

Walking the talk

Although attention now is on refineries, recent fatal incidents at the Upper Big Branch Mine-South in West Virginia, the Kleen Energy power plant in Connecticut and the Imperial Sugar plant in Georgia suggest the need for a broader application of the lessons from Texas City.

“I think that all of those high-profile incidents underscore the need to be focused on safety culture, and systems for corporate and site safety management, and then overseeing those systems,” said Mark Farley, head of the environment, land use and natural resources section at the Houston office of law firm Pillsbury Winthrop Shaw Pittman LLP.

Refineries have highly redundant systems, and incidents usually result from a series of things going wrong in a certain order, said Farley, who served as one of the lead attorneys for the Baker panel. “That’s what makes this challenging because if things don’t line up exactly the right way, the accident doesn’t happen, and sometimes that can lead to a sense of complacency about the risk,” he added. Workers can experience a false sense of comfort when they do the wrong thing and nothing bad happens. “You weren’t safe, you were lucky,” he warned.

An effective safety culture creates an opportunity to correct deficiencies before an incident happens and learn from one that does occur.
He noted many companies now are built through mergers and acquisitions so each operating unit may come in with a different safety culture. To guard against risk, Farley recommended managers promptly address safety concerns.
“It’s not just that you have to talk the talk, you have to walk the talk,” he said. “And that means that your actions and decisions need to be consistent with the commitments that you make around safety. It’s not enough to say that safety is your No. 1 value and then take actions, make decisions that undercut that.”

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